The Blog

Mental Health Insurance Coverage Challenges

Mental Health Coverage
Has A Long Way To Go

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Despite
progress, mental health care is not always consistently or sufficiently covered
by health insurance. This is because providers may struggle to bill
appropriately to ensure reimbursement, patients may delay or avoid seeking
treatment out of concerns about cost or insurance coverage, or maybe not all
conditions or forms of treatment are covered. All of this adds up to serious
gaps in care, and barriers to providing truly integrated care.

The Mental Health Parity
and Addiction Equity Act of 2008 (MHPAEA) currently exists on the books to
prevent health insurance providers from imposing less favorable benefits on
those with mental health or substance use disorder (MH/SUD) than benefits
provided for medical/surgical purposes. Nevertheless, the US has never been at
more of a crossroads in terms of MH/SUD. Mental Health America recently
released “The State of Mental Health in America 2018”, and have produced these key findings:

● 18 percent of adults have a mental health condition. That's over 43 million
Americans; more than the populations of New York and Florida combined.

● Youth mental health is worsening. Rates of youth with severe
depression increased from 5.9 percent in 2012 to 8.2 percent in 2015. Even with
severe depression, 76 percent of youth are left with no or insufficient
treatment.

● More Americans have access to services... Access to insurance and
treatment increased, as healthcare reform has reduced the rates of uninsured
adults. The greatest decrease in uninsured Adults with mental illnesses was
seen in states that expanded Medicaid.

● ...But most Americans still lack access to care. 56 percent of American
adults with a mental illness do not receive treatment. Considering that nearly
half of all Americans have co-occurring substance abuse disorders, and 9.6
million experience suicidal ideation, that’s a lot of people.

● There is a serious mental health workforce shortage. In Alabama, for example,
there’s only one mental health professional per 1,260 people.

Unfortunately,
the gap between health insurance and mental health treatment is only fueling
the fire, and mental health treatment in the US will only advance once the
relationship between the two is reconciled.

Health Insurance and Mental
Health

The
American Psychological Association (APA) found via a 2014 Survey that more than
90 percent of Americans are unfamiliar
with with mental health parity laws, whether that means what those laws
provide, or even that they exist at all. In a nutshell, the APA explains that
medical/surgical and MH/SUD parity can be illustrated as such: “An insurance
company can't charge a $40 copay for office visits to a mental health
professional such as a psychologist if it only charges a $20 copay for most
medical/surgical office visits,” they write. “The parity law also covers
non-financial treatment limits. For instance, limits on the number of mental
health visits allowed in a year were once common. The law has essentially
eliminated such annual limits.”

As of
2014, most individual and small group health insurance plans, including plans
sold on the Marketplace are required to cover MH/SUD services, according to
MentalHealth.gov. They also report that Medicaid and Medicare offer varying
degrees of services and support.

State
Medicaid programs provide some services, while Children’s Health Insurance
Program (CHIP) beneficiaries receive a full service array. States will
generally determine which services they’ll cover for adults, but it’s required
by Medicaid and CHIP that children receive a wide variety of services that
include counseling, therapy, medication management, social work services, peer
support, and substance use disorder treatment. Fortunately, essential health
benefits, including MH/SUD benefits and coverage, are required by the new
Medicaid adult expansion.

Patient Barriers to Treatment and
Insurance

Unfortunately,
even with the regulations that currently exist, there are still barriers that
prevent patients from attaining the proper treatment and adequate insurance.
For example, the parity law doesn’t actually require insurers to provide mental
health benefits — they simply require that, if
these insurers do provide those types
of benefits, they can’t be more restrictive than other types of general
benefits.

Another
problem that patients may face is that their specific diagnosis might not be
covered by the plans that employers or the majority of the Health Insurance
Marketplace may offer. This is because any health plan is allowed to
specifically exclude certain diagnoses, whether in the realm of MH/SUD or
physical health.

Last
but definitely not least, there are insurance companies that may not actually
be complying with the parity laws. It’s worth it to tap into your HR department
at work, and to report and track problems through them — or, if you don’t have
an HR department or your insurance isn’t provided through your employer, you’ll
want to reach out directly to your provider or the state insurance commissioner
if you obtained your insurance through an exchange.

The APA suggests that if you still have “unanswered questions or wish
to file a parity complaint, visit the U.S. Department of Labor's Employee
Benefits Security Administration (EBSA) Consumer Assistance web page — from there you can click
on “Ask a Question,” “Submit a Complaint,” or “Report a Problem.” You can also
call the EBSA toll-free consumer assistance line at 866-444-3272. The federal
government's Consumer Assistance
Program webpage is another good resource.”

Mental Health Provider Challenges

Providers
face similar challenges in terms of dealing with MH/SUD and physical health
parity. New analysis shows that lower payments to providers and wide
disparities in access to benefits are propping up the inequalities between
mental and physical health care.

“Physical
healthcare providers were paid, on average, about 20 percent higher rates than
behavioral health providers for the very same office visits billed under
identical or similar codes,” Psychiatry.org reports. “In many states, the
disparities in payment rates were 2-3 times greater.”

It
happens all too often that insurance companies will try to find ways to avoid
or delay payments to providers for legitimate medical claims — and beyond claims and appeals, there isn’t much providers
can do. When dealing with insurance companies and rightfully owed reimbursements,
we offer these medical billing tips
and best practices:

● When talking to an insurance
company, ask for a reference number for the phone call

● Don’t be ashamed to ask for a
higher-level employee. Not everyone at an insurance company has the same
abilities to help you.

● When a claim has not been
paid or responded to after 30 days, file a first level appeal.

● If claims are denied, ensure
that you exhaust administrative remedies by filing two timely appeals. Failure
to do so could preclude you from filing a formal complaint against the health
plan.

● For clinical denials for lack
of medical necessity or experimental, consider filing external, independent
appeals which are allowed in most jurisdictions. Personnel outside the
insurance company decide these appeals

● Don’t forget that you can
always file complaints with insurance regulators (for non-ERISA Plans) and with
the Health Bureau with the US Department of Labor (for ERISA Plans).

There
are still wide gaps to bridge before mental health care and insurance coverage
are really on even footing. Until then, it’s up to you to educate and protect
yourself as best you can — and when your best isn’t enough, look to outside
parties for help. You’re not the only person or entity that wants to keep
insurance companies accountable in today’s world.